Complementary medicine

On February 22nd the UK government Science and Technology Committee published Evidence Check 2: Homeopathy and concluded that “the NHS should cease funding homeopathy”. Hurrah!

It also noted that ”the Medicines and Healthcare products Regulatory Agency (MHRA) should not allow homeopathic product labels to make medical claims without evidence of efficacy. As they are not medicines, homeopathic products should no longer be licensed by the MHRA.” Hurrah again.

But this is the really really interesting bit. “In the Committee’s view,
homeopathy is a placebo treatment and the government should have a policy on prescribing placebos.”. They go on to say that placebos involve deception, and are not consistent with informed consent.

I don’t think I would have bothered the Advertising Standards Authority over vitamin water, except for two things. On a fast trip to London, adverts for it were on the tube everywhere (“with vitamin B and zinc to help you spend less time reading old magazines in the doctor’s waiting room” “keep perky when you’re feeling murky” “sometimes we all need an injection of strength” etc, etc) and a very intelligent friend, of whom I am most fond, who appeared one day with a bottle of this coloured liquid in her hand.

You won’t always be able to feel it in your bones. Osteoporosis, a condition in which the bones become thin or brittle, often stays well hidden, until a minor fall results in a major injury. A broken hip, perhaps, or broken wrist. Scans can reveal thinning of the bones, but in the NHS they are mainly reserved for people who have already had a fracture or are thought to be at increased risk of one. Private companies, meanwhile, have made use of small, easily transportable scanners in order to offer bone density tests at community venues such as church halls or shopping malls.

There is no doubt that osteoporosis is a serious health problem. One in three women and one in 12 men over the age of 50 are estimated to suffer a fracture due to osteoporosis at some point. Hip fractures can have grave consequences: half of patients are unable to live independently thereafter; one in five dies within six months.

Prevention, of course, is better than cure. Weight-bearing exercises, such as walking or aerobics, can help. Studies have also suggested that strength and balance training can also be effective. In addition, it is important to maintain a reasonable weight (being underweight is a risk factor), and to have a diet with sufficient calcium.

“It won’t hurt, and it might even help.” So goes the philosophy which some people use to justify their use of complementary medicine. Some doctors accept this, thinking that it is good if people can exercise a bit of control in a difficult medical situation. Other more cynical types like me argue that the harm could still be present – wasting time, resources or meaning that effective treatment was missed or delayed.

So are alternative treatments harmful? There are at least two problems with the study: it was neither randomised nor double blind, but observational. There may have been a factor or factors associated with people using alternative interventions that made them less likely to concieve, which was not the fault of the alternative medicine itself.

Second, the researchers haven’t given full details of the interventions – CAM is a broad term. But the results are interesting, and the subject merits further investigation. The usual teaching to medical students is to only use in pregnancy what you know to be safe, or when you have carefully weighted up the pros and cons with the woman. This approach should apply to complementary interventions too.

My eldest and I have been giggling at a book “F in Exams: The Funniest Test Paper Blunders”, which includes such gems as:

Q: Name two religions.

A: The Force (Jedi) and Football.

This amused us greatly.

What’s the difference with this next multiple choice one?.

Q: Which of the following explain(s) the physiological relationships between qi and blood/xue.

A: Qi is the source of all material in the body and blood carries the energy

B: Blood is the source of all material in the body including Qi

C: Qi drives blood moving and blood carries Qi

D: Qi flows in the channels and blood is stored in organs

E: Qi produce blood and blood is the mother of Qi

Well, this is a real exam paper, and it isn’t funny. It is an exam paper from Salford University’s Traditional Chinese Medicine course. The wonderful David Colquhoun gives access to the full paper plus the story behind the Pittilo report.

This report would, if implemented, create lots more nonsense exam papers funded by a lot more public money – and would produce practitioners without the absolutely crucial skill of how to assess evidence and reject or use it appropriatly.

As a GP, this makes me very concerned – after all, if someone has a degree, and is “regulated” by the government, surely you’d think the “treatment” on offer works? Sadly, and worryingly, no.

On the one hand, those who believe in acupuncture have accused me of being unfair to complementary medicine. At the other end of the scale, alternative medicine sceptics have said I am too interested in what acupuncture has to offer.

In order to solve this long-running debate once and for all, I’d like to see a new trial comparing three groups of treatment intervention for lower back pain.

One group would have standard NHS care, of the time-pressed variety we are all familiar with. The second group would be given acupuncture, or rather “sham” acupuncture (for those who have not read last week’s column, this involves toothpicks, cotton wool and the illusion that acupuncture is taking place). A third group would have all the aspects of care of the second – sympathetic and understanding treatment, longer appointment times, continuity of care etc – but no acupuncture. Then let’s see how they match up.

In other words, I want to know about the role of the ’caring effect’. We already know that the care of doctors and health professionals is extremely important to patients, and forms an important part of treatment. I suspect that at least part of what acupuncture has to offer is related to the idea of having your problem treated in a caring and understanding way.

In my view, it is vital we recognise these caring effects and make use of them. It seems to me that the NHS measures many things - but not this.

It would be truly sad if the only people taking the nation of care seriously were those working in the alternative medicine industry. I suspect that many NHS doctors entered the vocation wanting to care for thier patients but ended up doing things largely dictated by targets. And these do not always serve the patients best.

Simon Singh, as mentioned before, was in the High Court last week facing the British Chiropractic Association over an article he wrote for the Guardian (which is no longer available to read on their website.)

In court, the Judge held that the phrase Singh used – ”happily promotes bogus treatments” – was capable of bearing the meaning that the BCA was being knowingly dishonest in using treatments (in the article, Singh was referring to the treatment of certain childrens ailments) they knew to be ineffective. The BCA sued for libel over this claim, and in court it was held that Singh would either need to defend, settle or appeal regarding the meaning of his article.

It goes without saying I am disappointed about this. The best way to have a discussion about evidence is transparantly, preferably unthreateningly, and in the public domain. Much of this has been done, quietly, already. For example, the Cochrane Collaboration -an international organisation which searches for evidence on healthcare interventions, assesses it for quality and disseminates its results – has examined some evidence on chiropractic, and other reviews are ongoing:

For example, one review of manipulation and mobilisation for neck pain found that :

“This review of 33 trials did not favour manipulation or mobilisation done alone or in combination with various other physical medicine agents. It was unclear if manipulation and mobilisation performed in combination were beneficial, but when compared to one another, neither was superior.”

Or there’s a review of the evidence for using chiropractic to treat asthma which concludes :

Some large studies suggest some benefit, for example the UK Beam Trial, which looked at the effectiveness of exercise and manipulation for back pain. But there are, I think, also valid criticisms of this trial – for example, the high drop-out rate, and the indices used to measure improvement.

Thus, we can say that there is some evidence for chiropractic in certain situations. What I am unclear about it whether it is any better than the combination of exercise, physiotherapy and pain relief I will commonly advise. Moreover, a Cochrane review from 1994 concludes that, “There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.”

However, yesterday NICE recommended chiropractic treatment for low back pain, as well as acupuncture “needling” (there is a column coming up about this, but briefly: we know that sham and even needle-free acupuncture is as good an intervention as full acupuncture.)

To make it clear, I am no more “against” chiropractic than I am for or against any other kind of medical intervention. The judgement about using or recommending something should be about; the chances of it working, its potential to harm, the cost-effectiveness of the intervention, and how a patient feels about using it. This means using evidence and assessing it for fairness.

You may also be interested in the judgement the ASA made recently about a chiropracter’s clinic . So what is “bogus”? And how are consumers to be helped to sort this out?

Clive Cookson has been a science journalist for the whole of his working life. He joined the FT in 1987. Clive, the FT's science editor, picks out the research that everyone should know about. He also discusses key policy issues, from R&D funding to science education.

Andrew Jack is pharmaceuticals correspondent, covering the industry and public health issues. He has been a journalist with the FT for 19 years, based in London, Paris and Moscow